RESEARCH ARTICLE
Diet-Cancer Related Beliefs, Knowledge, Norms,
and Their Relationship to Healthful Diets
RUTH E. PATTERSON,! ALAN R. KRISTAL,! JAMES
ICancer Prevention Research Program, Fred Hutchinson Cancer Research Center, Seattle, Washington 98104;
and 2Department of Biostatistics, University of Washington, Seattle, Washington
ABSTRACT Our objective was to examine the prevalence
of diet- and cancer-related psychosocIal constructs in a popu-
lation-based sample and their association with healthful diets.
We administered a random digit dial survey on cancer-related
risk behavior to 1972 adult Washington state residents. The
psychosocial constructs were belief in an association between
diet and cancer, knowledge of National Cancer Institute diet
recommendations, knowledge of fat and fiber composition of
foods, and perceived pressure to eat a healthful diet (norms).
Diet measures were self-reported healthful diet changes over
the previous 5 years, percent energy from fat, and dietary fiber.
Age and education were significantly (p ::; .001) related to the
constructs. Older adults (60+) had the lowest levels of belief,
knowledge, and perceived norms. Participants with strong
beliefs in a diet-cancer connection consumed 1.1 grams more
fiber than those with no belief (p for trend ::; .001), and
participants with excellent knowledge of food composition
consumed 2.1% less energy from fat than those with low
knowledge (p for trend::; .001). Perceived norms were only
weakly associated with fat and fiber intake. Intervention strate-
gies, targeting beliefs and knowledge may help people adopt
more healthful diets. The findings on perceived norms suggest
that extrinsic motivations (such as pressure from others) may
be less effectIve than intrinsic mOtIvatIOns (such as beliefs) on
promoting healthful behaviors.
(fNE 27:86-92, 1995)
INTRODUCTION
The National Cancer Institute (NCI) has recommended
that Americans decrease their consumption of fat to 30% or
less of total calories and increase fiber consumption to 20
to 30 grams per day.! These recommendations are based on
The research was supported by Grant CA-34847 (Cancer Preventton Research
Program) and Grant CA-09661 (Cancer PreventIOn Traming Program) from the
N atIOnal Cancer Instltute.
Address for correspondmg: Ruth E, Patterson, Ph.D, R,D , Cancer Prevention
Research Program, Fred Hutchmson Cancer Research Center, 1124 ColumbJa,
MP 702; Seatte, WA 98104; Tel: (206) 667-5014, Fax (206) 667-5977.
© 1995 SOCIETY FOR NUTRITION EDUCATION
86
C. LYNCH,I,2 AND EMILY WHITE 1
a convergence of results from laboratory and epidemiologic
research that suggests that fat can increase the risk of certain
cancers while fruits, vegetables, and whole grains are pro-
tective. 2- s There are many ongoing activities to deliver the
diet and cancer message to the public, including govern-
ment health promotion programs, food advertising, and
community intervention trials .H2 However, there is still
much to learn about the most effective means of improving
diet habits in the general public. In particular, there is little
consensus on the components of community-based inter-
ventions that are most effective for initiating and maintain-
ing dietary change.!3
Programs to improve eating patterns are more likely to
be effective when they are based on established theory and
research on changing health-related behavior. 14 Of particu-
lar interest for designing mterventions to promote healthful
diets are constructs derived from social cognitive theory,
the theory of reasoned action, consumer information proc-
essing, and the Health Belief Model. 15 Key elements of these
theories are that improvements in diet are related to changes
in (1) beliefs about diet and health, (2) knowledge and skills
related to selecting healthful diets, and (3) social norms
regarding expectations about an individual's behavior.
Here, we give a brief overview of these constructs .
The beliifthat a particular health practice will be effective
in reducing a threat is an integral part of the Health Belief
Model. 16 Thus, the Health Belief Model assumes that if
people can be persuaded that their current health habits are
potentially harmful, they will be motivated to change those
health habits. Information campaigns assume that lack of
knowledge is a barrier to improving health behaviors, espe-
cially for a health practice as complex as diet. Knowledge
about diet and cancer can be general, such as knowledge of
dietary recommendations, or specific, such as information
on the fat and fiber composition of foods. Finally, a com-
ponent of the Theory of Reasoned Action 17 suggests that
perceived norms (behavioral expectations of peers and family
members) have an influence on health behaviors. More
detailed descriptions of the theoretical motivations for these
constructs are given by Glanz.!8
Journal of NutntlOn EducatlOn Volume 27 Number 2
Some researchers have studied how psychosocial con-
structs relate to healthful eating patterns,19 low-calorie,
low-fat eating behavior during a weight loss course,20 and
health-oriented beverage consumption. 21 Only recently
have researchers addressed predictors of selecting low-fat,
hIgh fruit and vegetable diets. 22 - 25 In general, there is some
consistency in findings that beliefs in a strong relationship
between diet and health and personal motives to eat a
healthful diet predict healthful diet behaviors. It is less clear
whether environmental factors, especially social support or
perceived norms, influence dietary habits.
We hypothesized that certain psychosocial constructs
(belief in an association between diet and cancer, knowl-
edge of diet recommendatlOns, knowledge of fat and fiber
composition of foods, and perceived no=s) are positively
related to healthful diets. We examined this question using
data from a random digit dial survey sample, representative
of the state of Washington. Population-based samples are
important because much of the early research on improving
individuals' diets was performed in traditional clinical set-
tings, with small, select samples and individual counseling
techniques; therefore, neither the techniques nor the results
can be directly applied to community-based nutrition inter-
vention programs. 13 This study can help health promotion
practitioners and program planners develop, focus, and
target community-based interventions by testing the asso-
ciations used in the design of public health interventions.
METHODS
Participants. Study participants were randomly selected
adults (18 years of age and older) residing in Washington
state. Data were collected from August 1989 through April
1990 ~s part of the Washington State Cancer Risk Behavior
Survey (CRBS), a random digit dial survey to monitor
cancer risk behavior. The CRBS was part of a NCI -funded
program project on the primary prevention of cancer. Goals
of the CRBS are to monitor changes in behavior and
attitudes related to cancer risk and prevention, with empha-
sis on diet, smoking, and screening. Details of sample
selection and statistical methods have been published. 26
Sample frame. Telephone numbers were selected using
a modified, two-stage Waksburg method27 in which random
four-digit numbers were affixed to each telephone prefix
within Washington state's two area codes. The sample of
telephone numbers was selected to be representative of the
entire state and was based on the distribution of residential
lines for each prefix. For each telephone number in the
sample, 11 attempts to contact an individual were made in
the first month of calling. Once it was dete=ined that the
phone number reached a household with at least one adult,
a screening process was used to select at random one man
and one woman from each household. For each randomly
March. Apnl 1995 87
selected telephone number (i.e., household), one eligible
adult of each gender was mterviewed. In female- or male-
only households, only one person was interviewed. To
select participants, a modification of the Troldahl and Car-
ter28 procedure was used in which selection of a random
adult is based on the total number of adults in the household
and the number of men and/or women. A series of tables
are then used to specity the gender and age range of the
selected respondent (e.g., "oldest male" or "second oldest
female").
Survey instrument. The annual CRBS survey consists
of a core set of questlOns on risk factors for cancer, including
dietary habits, sun exposure, alcohol consumption, smoking
behavior, preventive cancer screening, and self-rated health
and standard demographic items. The questionnaIre was
administered using a computer-aided telephone interview
(CATI) system and took an average of 25 minutes to
complete. (Copies of the survey instrument are available
from the authors.) The response rate (completed interviews
divided by known elIgibles) was 0.75 for females and 0.61
for males, and the conservatively estimated effective rate
(completed interviews divided by estimated eligibles) was
0.65 for females and 0.53 for males. 26 These response rates
are somewhat less than optimal and may raise concerns
about the generalizability of study results. Therefore, in a
separate but related study, we used enhanced calling efforts
to increase overall survey response rate. We were able to
increase the response rate by 11 %, and observed that there
were some demographic differences among the participants
reached at different levels of calling effort. However, there
were no consistent associations of calling effort with health
behavior related to dIet. 26
Measures. We measured belief in the assooatlOn be-
tween diet and cancer by asking partiCIpants if they believed
that there was an association and, if they responded yes,
whether the association was weak, moderate, or strong. For
analysis, we grouped no association with weak.
We developed a measure of knowledge of NCI diet
recommendations using the following procedure. We told
participants that NCI has made recommendations about
how people can change their diet to lower their risk of
disease. We asked if they could recall any of these as specific
food recommendations (yes/no) and, if so, what these
recommendations were (open-ended response). Partici-
pants were categorized as having no knowledge if they were
unable to recall any diet recommendation. Participants were
coded as having some knowledge if they recalled any
sensible diet recommendation (e.g., "eat more chicken" or
"eat more carrots"). Participants were categorized as having
knowledge of the fat and/ or fiber goal if they stated the goal
explicitly ("eat less fat" or "eat more fiber") or mentioned
two or more diet changes relating to a single goal. For
example, if a participant answered "eat less butter" and "eat
88 Patterson et al./DIET-CANCER BELIEFS AND HEALTHFUL DIETS
less red meat, " they were coded as having knowledge of the
NCI diet recommendation to eat less fat. We did not
require nutritionally precise answers (e.g., less than 30%
kcals from fat) because our purpose was to obtain a measure
of general knowledge about foods/nutrients and cancer risk.
We developed a measure of practical knowledge about
how to select a healthful diet using questions on the fiber
and fat content of food. For 12 foods, participants were
asked which foods they thought were high in fat (white
bread, whole milk, butter, margarine, etc.) For another 12
foods, participants were asked which foods they thought
were high in fiber (white bread, skim milk, baked potatoes,
etc.) We summed the number of correct responses and
categorized the summary score as low (0-15 correct re-
sponses), intermediate (16-19 correct responses), and high
knowledge (20-24 correct responses).
In this report, we define perceived norms as a measure
of perceived pressure to adopt a healthy diet. This definition
is related to the construct of extrinsic motivation as defined
by Curry et al., 29 who state that extrinsically motivated
behaviors are those that a person performs to receive some
extrinsic reward, while intrinsically motivated behaviors are
ones for which the rewards are internal to the person. We
measured perceived norms from five questions on whether
the participant felt pressure to eat a healthy diet from the
people they live with, friends, coworkers, media, and their
doctor. We scored the responses as 3 (a lot), 2 (some), or 1
(none) and used the average as a summary measure. This
perceived norms scale had an alpha coefficient of 0.62, an
indication of good internal consistency.30
Our outcome measures were three measures of diet:
self-reported healthful diet changes, percent energy from
fat, and dietary fiber. We assessed diet changes by asking
participants whether their intake of 12 foods had decreased,
increased, or stayed the same over the previous 5 years. For
this measure, we chose a mix offive foods high in fat (whole
milk, butter, margarine, cheese, eggs, red meat), five foods
high in fiber (fruits, vegetables, whole wheat bread, whole
grains), and two foods that were neither (fish and alcohol).
These items were developed by White et al. 31 to examine
dietary change among husbands of participants in a low-fat
dietary intervention and have proven useful in other studies
of dietary change. 32 We summed the number of healthful
changes to make a scale from 0 to 12.
We assessed current diet quality using the Quick Dietary
Screen (QDS). The QDS consists of three sets of items: 16
questions about whether a food was eaten daily, 28 ques-
tions about whether a food was eaten at least weekly, and
2 questions about frequency of consumption of red meat
and use of butter or margarine in breads. Details of the
development of this assessment instrument have been pub-
lished. 33 In a validation study, correlations between a tele-
phone-administered QDS and two 4-day food records, a
food frequency questionnaire, or the average of both were
0.54, 0.65, and 0.65 for percent energy from fat and 0.38,
0.43, and 0.47 for dietary fiber. 33 The correlations for fiber
were less than optimal and may introduce additional noise
in our nutrient estimates. Because data collection was in the
fall and winter, our point estimates for fat and fiber intake
may be slightly biased because of seasonal reporting bias 34;
however, this should not affect the relationship between the
dietary variables and psychosocial factors.
Statistical analyses. Descriptive analyses of the distribu-
tion of diet and cancer beliefs, knowledge of NCI diet
recommendations, knowledge of food composition, and
perceived norms by age and education (Table 1) are
weighted for the complex survey design, and these results
are representative of the Washington state population. As
required by the design of the survey, these results are
presented separately for males and females. The derivation
of the sample weights IS given in Kristal et aJ.26 We used
chi-square tests to detect the presence of a statistically
significant association of age and education with diet and
cancer beliefs, knowledge, or perceived norms. Statistical
tests in Table 1 were based on weighted data, but the
weights were standardized so the sum of the weights
equaled the number of persons interviewed.
We used multiple linear regression to model the effects
of belief, knowledge, and perceived norms on the dietary
outcomes. Results related to relationships between beliefs,
knowledge, perceived norms and diet (Table 2) were un-
weighted but adjusted for the following covariates: gender,
age (three categories: 18-34,35-59,60+), education (years)
and self-rated health (four categories: poor/fair, good, very
good, excellent). We categorized age because of its non-
linear association with diet. We also included a gender by
age interaction in all models, which was the only statistically
significant pairwise interaction among the covariates. A
linear contrast was used to test for trend across the categories
of belief, knowledge, and perceived norms.
RESULTS
Study sample characteristics. Of the 1967 survey par-
ticipants with complete data used in this research, 33% were
aged 18-34, 47% were 35-59, and 21 % were 60 or older.
Forty-two percent of the participants were males, 95% were
white, 59% had some college or post-secondary education,
and 86% rated their own health as good or excellent.
Diet-cancer beliefs, knowledge, and perceived
norms. The distribution of diet-cancer beliefs, knowl-
edge of NCI diet recommendations, knowledge of food
composition, and perceived norms by age and education for
men and women are given in Table 1. Age was significantly
related to all four constructs. Adults aged 35 to 59 had the
strongest belief in the association of diet and cancer and the
most knowledge about NCI recommendations and food
Journal of Nutrition Education Volume 27 Number 2 March. April 1995 89

Table 1. Distribution (percent) of belief, knowledge, and perceived norms related to diet and cancer by sex, age, and education (adjusted to
Washington state 1989 census).

Females Males

Age (Column Percents)

18-34 35-59 60+ 18-34 35-59 60+

N 360 533 250 282 397 145

Belief in diet-cancer connection
None-weak 34a 24 50 43 a 33 57
Moderate 44 37 24 36 39 22
Strong 22 38 25 21 28 21
Knowledge of National Cancer Institute diet recommendations
None 21 a 12 32 32a 22 44
Some 17 12 17 19 14 15
Fat or fiber goal 41 39 28 31 39 22
Fat and fiber goal 20 36 23 17 25 19
Knowledge of food composition
Low 14a 7 21 14b 22 20
Intermediate 52 49 53 57 46 56
High 34 45 26 28 31 24
Perceived pressure to eat a healthy diet
None 9a 15 37 15a 17 41
Some 28 40 34 43 38 26
Strong 62 45 29 42 45 33

Years of EducatIOn (Column Percents)

:s: 12 13-15 16+ :s: 12 13-15 16+

N 513 327 303 285 242 297

Belief in diet-cancer connection
None-weak 46 a 27 18 52a 47 25
Moderate 29 41 46 26 32 45
Strong 25 32 36 21 21 30
Knowledge of National Cancer Institute diet recommendations
None 28 a 18 6 42 a 30 19
Some 20 12 9 14 20 15
Fat or fiber goal 36 40 37 29 31 38
Fat and fiber goal 16 30 48 14 18 29
Knowledge of food composition
Low 19a 7 6 28 a 19 11
Intermediate 55 52 42 51 59 47
High 26 41 52 21 22 42
Perceived pressure to eat a healthy diet
None 19 15 20 22 c 24 14
Some 34 36 33 39 36 38
Strong 47 49 47 39 40 47

a Chi-square test for distribution statistically significant (p < .001).

bChi-square test for distribution statistically significant (p < .01).
c Chi-square test for distribution statistically significant (p < .05).
90 Patterson et al./DIET-CANCER BELIEFS AND HEALTHFUL DIETS

Table 2. Relations of diet-cancer belief, knowledge, and social norms to healthful diets (adjusted for gender, age, and education and self-related
health).

Diet Measures (Means)

Na Healthful % Energy Fiber

Changes b from Fat (Grams)

Belief in diet-cancer connection

None-weak 645 4.9 35.2 12.9
Moderate 678 5.1 35.1 12.7
Strong 482 6.0 33.5 14.0
P for trend 0.001 0.001 0.001
Knowledge of National Cancer Institute diet recommendations
None 490 4.2 35.6 12.7
Some 299 5.0 35.6 12.6
Fat or fiber goal 689 5.7 34.4 13.2
Fat and fiber goal 489 59 34.0 13.4
P for trend 0.001 0.001 0.001
Knowledge of food composition
Poor 274 4.0 36.3 12.4
Fair 1036 5.4 34.9 13.1
Excellent 657 5.6 342 13.3
P for trend 0.001 0.001 0.001
Perceived pressure to eat a healthy diet
None 361 4.1 35.0 13.1
Some 719 5.0 35.1 12.8
A lot 887 5.9 34.6 13.2
P for trend 0.001 0.06 0.004

a Sample sizes vary due to missing data.

b Number of changes to lower fat or higher fiber foods that people reported making over the past 5 years.

composition, while older adults (60+) had the lowest levels
of belief, knowledge, and perceived norms. For example,
50% of older females and 57% of older males believed that
there was no connection between diet and cancer compared
to only 24% and 33% (females and males, respectively) of
middle-aged adults and 34% and 43% of younger adults.
Young women (18-34) perceived the greatest pressure to
eat a healthy diet, with 62% reporting that they perceived
a lot of pressure to eat a healthy diet. Conversely, among
older adults, only about 30% reported feeling strong pres-
sure to eat a healthy diet.
Diet-cancer beliefs and knowledge were positively asso-
ciated with higher education (p < .001). Perceived nonns
were not significantly associated with education in females
and only marginally for males. Among participants with
high school or less education, about 50% of men and
women believed that there was no connection between diet
and cancer, 28% of females and 42% of males had no
knowledge of NCI diet recommendations, and 19% and
28% had low knowledge of food composition. However,
among participants with college degrees, only 18% of fe-
males and 25% of males believed that there was no connec-
tion between diet and cancer, 6% and 19% know no NCI
diet recommendations, and 6% and 11 % had low knowl-
edge of food composition. Education had little effect on
perceived nonns, with approximately 50% of females and
40% of males at all education levels reporting feeling strong
pressure to eat a healthy diet.
Associations between diet-cancer beliefs, knowl-
edge, perceived norms, and diet. The relationships
of diet-cancer beliefs, knowledge of NCI recommenda-
tions, knowledge of food composition, and perceived
norms with three measures of diet (controlled for gender,
age, education, and self-rated health) are given in Table 2.
After adjustment for sociodemographic covariates, all four
constructs were significantly associated with reported
healthful diet changes. The number of healthful diet
changes reported by participants appeared to be most influ-
enced by perceived norms. Individuals who perceived
Journal of Nutntion EducatIOn Volume 27 Number 2
strong pressure to eat a healthful diet made 1.8 more
healthful changes (5.9 vs. 4.1) in the past 5 years compared
to those who felt no pressure (p for trend:::; .001). Among
the predictors of dietary intake, the largest improvements
(decreases in fat intake and increases in fiber intake) were
among individuals with good knowledge of food composi-
tion. The largest improvements in diet were seen for beliefs
and knowledge. Participants with strong beliefs in a diet-
cancer connection consumed 1.1 grams more fiber than
those with no belief (p for trend:::; .001), and participants
with excellent knowledge of food composition consumed
2.1 % less energy from fat than those wIth low knowledge
(p for trend :::; .001). Although perceived norms were
strongly associated with reported healthful diet changes,
there was only a weak association with eStimated fat and
fiber intake.
DISCUSSION
Results of this random digit dial survey suggest that most
Washington state residents believe that what they eat is
related to their chance of getting cancer. Further, we found
that state residents were fairly knowledgeable about the
NCI diet recommendations and fat and fiber composItion
of food and felt pressure from their family, friends, and
coworkers to eat a healthy diet. These findings are similar
to the Cancer Control Supplement of the 1987 National
Health Interview Survey (NHIS), in which 73% of Ameri-
cans agreed that cancer may be related to what people eat
or drink. 35 Participants in the NHIS were also asked open-
ended questions on foods that they thought affected a
person's risk of getting cancer. These results were very
similar to our findings in that individuals who were most
likely" to correctly identify foods to eat more (or less) to
prevent cancer were females, adults aged 35 to 49 (as
compared to younger and older adults), and more educated
participants.
It is notable that people aged 60 and older were least
likely to believe in a connection between diet and cancer,
have knowledge of NCI diet recommendations or food
composition, or to feel pressure to eat a healthy diet. This
finding is in contrast to research that indicates that older
people are very interested in their health and willing to
improve their behaviors to improve their health. 36 ,37 In
focus group discussions with older Americans performed by
the Public Health Service, nutrition was an issue of wide-
spread concern; however, most individuals were unable to
describe what constitutes a balanced diet and there was
confusion over basic issues such as what fiber is or whether
red meat should be included in one's diet,38 Additional
research should be done to indicate whether community-
based interventions need to be specifically focused and
tailored to have a positive impact on the diet of elderly
Americans.
March. April 1995 91
Few studies have examined the relationships between
diet-cancer beliefs, knowledge, and perceived norms with
healthful diet, and we are not aware of any published
research using a representative, population-based sample.
Our results indicate that beliefs and knowledge are signifi-
cantly associated with having a healthful diet. Comparisons
of our results with other studies are difficult because of
differences in sample and measures, In a previous study, we
used carefully designed scales in a select sample of post-
menopausal women and found that the psychosocial factors
most strongly associated with selecting low-fat diets were
related to knowledge about fat in foods and perceived
norms,24 Conversely, a study of a convenience sample of
210 English adults found that knowledge offood composi-
tion was not associated with frequency of intake of five high-
fat foods, and personal attitudes were much more important
than perceived norms in predicting consumption of high-fat
foods. 39 Glanz et aJ.25 examined similar psychosocial items
in a pilot study of 652 working men and women and found
that beliefs, food composition knowledge, and social sup-
port were weakly associated with fat or fiber in the diet,
Perceived norms were strongly associated with reported
healthful diet changes, but they were only weakly associated
with dietary fat and fiber intake, It may be that questions
about healthful diet changes are subject to considerable
social desirability bias, The negative findings on perceived
norms and healthful diet appear to echo the work in smok-
ing cessation by Curry et aL;o suggesting that extrinsic
motivations (such as reward or perceived pressure by others)
may be less effective than intrinsic motivations (such as
beliefs) on behavior change, She found that the rate of
continuous smoking abstinence at 1-year post-intervention
was more than twice as high in the group receiving intrinsic
versus extnnsic motivation strategies,
One caveat to this study concerns the QDS. This instru-
ment is a relatively brief assessment tool; therefore, the
associatlOns between dietary intake and psychosocial meas-
ures were not as strong as would be expected had we used
longer, more intensive instruments such as food records or
frequencies.
Young people, older adults, males, and the less educated
appear to be important targets for nutrition interventions,
Our results suggest that strategies that focus on beliefs about
diet and health and knowledge about fat and fiber content
of food may help people adopt more healthful diets. How-
ever, it is important to note that this is a cross-sectional
study, and therefore it is not possible to determine true
causality, A belief in a diet and disease connection and a
healthy diet may both result from underlying factors that
were not measured in this study. In addition, much addi-
tional research is needed on strategies for affecting beliefs
and knowledge in a community, Results from ongoing
trials, such as the Working Well Study,!! should further
elucidate the optimal components and strategies for com-
munity-based diet change interventions.
92 Patterson et al.lDIET-CANCER BELIEFS AND HEALTHFUL DIETS
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